Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I am your host, Dr. Nathan Fox, an OBGYN and maternal fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness.
Welcome to our 38th “Mailbag” podcast, “What Does the Fox Say?” Our first question is from an anonymous listener. “Hi, Dr. Fox. Can you discuss the use of continuous glucose monitoring, or CGM, for pregnant women with gestational diabetes? I have a history of gestational diabetes, and would love to avoid months of finger sticks if I have another pregnancy. It seems like CGM would provide a lot of useful information for me since I tend to eat snacks and small meals throughout the day, especially later in pregnancy. What are the pros and cons of CGM, and how does your practice use CGM in your patients?”
All right. Really interesting topic. Great question. As some background, for someone with gestational diabetes, or frankly, anyone with diabetes, one of the things that is necessary to figure out about food and blood glucose and insulin and treatments, all these things, is what is the person’s blood glucose level? And if you want to know what it is sort of instantaneously, meaning at this moment, traditionally, the way we would do it is by what we call a finger stick, which is basically like a little device where you prick the tip of your finger, a little drop of blood comes off. You put that onto a little strip of paper, which goes into a handheld monitor, and it gives you a number, it gives you a value. We call those finger sticks. That is the traditional way that people would check their blood glucose, and how often you had to do it depends on what type of diabetes you have, whether you’re on medication or not on medication.
Traditionally, for gestational diabetes, for someone who has it in pregnancy, we would recommend doing that, the finger stick, four times a day. The first one, you would do what we call fasting, which is basically when you wake up in the morning, you haven’t eaten for the past whatever amount of hours, we call it fasting. And then you’ll do it after breakfast, after lunch, and after dinner, usually an hour or two hours. Different people do it differently, but basically after the three meals, and that gets to four times a day. And using those values, you determine how is the gestational diabetes controlled? Do we need to change the diet? Do we need to start medication? If you’re on medication, do we need to change the dose of medication? That’s what we would do. Okay. So, that’s the traditional way.
A continuous glucose monitor, for those who do not know, is basically a little device that attaches to your body. Most people will place it on the back of their arm. It’s not particularly big. And essentially, it has a little needle that goes into the skin, and it’s a sensor and it stays there. And it basically continuously monitors the level of your glucose. So, it’s like a finger stick after a finger stick after a finger stick after finger stick, basically continuously, hence the C in continuous glucose monitoring. And then that information is transferred. It can be transferred to a portable device, it can be transferred to something on your computer, on your iPhone, whatever it is. But basically, the information is transferred somewhere else. So, instead of having four data points in a given day, your four finger sticks, you will have sort of a continuous track of what your glucose is. It’s sort of like the difference between checking your pulse, like feeling your wrist and saying, hey, my pulse is 80, versus having what we call a pulse oximeter that sits on your finger, which checks your pulse continuously until you take it off.
So, that’s what we’re talking about here. There has been a lot of move towards CGM for people with non-pregnancy-related diabetes, particularly type 1 diabetes, because they’re going to get much more feedback on what’s going on with their blood sugar, particularly people who are taking a lot of insulin or maybe they’re on an insulin pump, which continuously gives them insulin. And if you think about it, conceptually, if someone has type 1 diabetes where their body does not make insulin, and you’re trying to sort of replicate what the body would normally do, sort of the ideal system is you have one part of your body that’s testing your glucose continuously, and another part of your body that’s giving you insulin based on what your glucose is, two sort of automated devices. That’s basically replacing what your body would do naturally. Your body normally would sense what the sugar is, and then your pancreas would release the amount of insulin you need. So, that’s sort of the high-level goal.
And so, there’s been a movement to both of those for non-pregnant type 1 diabetics, a sensor that’s continuous, insulin that’s continuous, and they play off each other. Fine. Now, the question is, how valuable is something like CGM in pregnant women? And there’s two components to that. The first is value in terms of does it improve outcomes? Does it lower risks of gestational diabetes? Is it “better” for someone to be using a CGM medically? That’s one question. And the second question is, do people find it easier to use? So, either one of those might be a valuable reason to use a CGM in pregnancy.
In terms of the first question, does using a CGM actually improve outcomes? Right now, I would say, unknown. There is some data suggesting it does, some data suggesting it does not. As far as I know, there isn’t data suggesting it’s worse or harmful to use a CGM, but it may or may not be better in terms of outcomes. And there’s probably a lot of reasons for that, and it probably also depends on how “bad” the gestational diabetes is. I would think the worse the gestational diabetes is, the more difficult it is to control, probably the more value a CGM would give you, compared to checking four times a day. So, since it’s not known to be better, it’s not universally recommended. A lot of insurance carriers won’t pay for it, for example. In all women with gestational diabetes, maybe they will, maybe they won’t, maybe they’ll only pay for it if someone’s on insulin for their gestational diabetes. I don’t really know. And that’s probably going to evolve over time, but it’s not sort of done for everyone, necessarily.
In terms of the second, is it more convenient? So, on the one hand, yes. For a lot of women, they find it more convenient because, A, they don’t like sticking their finger four times a day. It’s painful, it’s annoying. They have to figure out when they ate and then timing it, and it sort of just becomes irritating for them. For others, some people really love a lot of data, and they want to see exactly what’s going on, and it’s really helpful to them. Similarly, for doctors, sometimes they really prefer to get the continuous data versus the four points a day data, or they’re finding that, for the patient, they’re having a hard time doing this finger sticks four times a day, remembering to doing it, doing it at the right time. And all this is reasonable, and for that reason, they might prefer a CGM to finger sticks. But that’s obviously very personal.
What would be the downside to a CGM, sort of on a logistical level? Some people don’t like the overload of data. Others don’t like the fact that the CGM will sometimes have alarms that are set if the sugar is slightly too high or slightly too low, and it sort of makes people more anxious about it or worried about it. And so, that’s kind of a personal decision.
In our practice, what we do for women for gestational diabetes is we’re very comfortable if they have a CGM. We don’t necessarily push it on people, but a lot of people ask about it and we tell them it’s definitely an option. We also have sort of an app that we use that will integrate the data from their CGM so we can see it directly. They don’t have to send it to us. We can actually do the same with their finger sticks. So, that’s not necessarily a reason to use a CGM.
I would predict that people are going to be using CGMs more and more just as people get used to it and how to look at the data and interpret the data, how to analyze the data. Maybe in the future it’ll show that there’s more improved outcomes using CGM. Again, maybe it won’t, but I think for a lot of people, they just find it more convenient. And that might be another reason that more people use it.
Okay. Next question is from Hope, and it’s about umbilical cord edema. “Thank you for your wonderful podcast. It helped me in my fertility journey and pregnancy, and also helps in my profession as a NICU nurse.” Hey, Hope. Thanks for that. Strong work. “I’m curious to learn more about umbilical cord edema. I had a threatened placental abruption resulting in preterm labor at 35 weeks. I had retained placenta and lost 2.5 liters of blood. I gave birth when I was 35 years old, and my placenta was bilobed, if either of those facts are relevant. The placental pathology report says the umbilical cord was edematous. How common is cord edema? Is it an incidental finding, or is it somehow related to my two placenta problems? Thank you.”
Okay. So, for our listeners, edema is sort of the medical term for when there is fluid in something. So, swollen, for example, is another word for it, or thickened might be another word. If it’s thickened because of fluid, we would call that edema. And umbilical cord edema is not commonly discussed. It’s not something that we talk about day to day. And there’s sort of two ways you can note umbilical cord edema.
One way is the way you did, which is after delivery, someone looks at the cord, whether it’s a pathologist, whether it’s just whoever delivers it. Hey, that cord is a little thick. I think it’s edematous. Or the other way, potentially, is when you’re doing an ultrasound and you say, hey, the cord looks a little bit thick. I would say, the vast majority of the time, it does not mean anything and it is an incidental finding. There are situations where it can be found along with other edema or edematous parts. So, for example, in a baby that has a condition called hydrops, which is a very serious condition where there’s edema all over the baby, you can also see it in the cord. But then the problem is not that it’s in the cord, it’s that it’s in the baby, but you sometimes will see it.
There are other sort of circumstances where it might be relevant if there’s other issues with the placenta. But again, we don’t normally measure cord thickness on ultrasound. It’s not something that’s normally done. We don’t normally comment on it. It is true, sometimes we’ll see cords that are thicker than others. We usually don’t make much note of it.
Now, whether it was related to your bilobed placenta, which means the placenta has sort of two sections versus one big one, not that I know of. Maybe there’s some association, but not that I know of. Whether it was related to the fact that you had a potential abruption and a lot of blood loss, again, hard to say for sure. If the only thing was that the umbilical cord was a little bit thicker, then probably not. If there are other issues, sometimes the cord is a little bit thicker. If it has an issue with what’s called coiling, how much the cord twists. And coiling has been associated with some things. So, maybe there’s some relationship potentially, but if it was just a umbilical cord edema or swelling itself and nothing else, I would say, probably not. All right.
Next question, also related to a placenta from Kylie. “Hey, Dr. Fox. I love the podcast, and I’ve recommended it to all my friends.” Hey. Kylie, thank you. For all you listeners out there, please do the same. Recommend it to your friends. “My question is about pregnancy with an anterior placenta. When I was pregnant with my son, who is a thriving almost one-year-old, I had an anterior placenta, which made tracking consistent fetal movement nearly impossible. Baby would have very active days, followed by days where I felt little or no movement, even when we can see him moving via ultrasound. I mentioned this at every checkup, and my providers admitted that there wasn’t much that could be done besides trying to find a consistent pattern, which wasn’t very helpful. Nobody seemed overly concerned because the pregnancy seemed to be progressing normally, and the baby and I were healthy.”
“At my routine 34-week visit, when I casually mentioned to my OB that it was a ‘quieter’ movement day, I was sent for monitoring and my son ended up being delivered via emergency C-section the next morning because a placental infarction was causing him distress. I don’t know what would have happened if I didn’t have that appointment, but I’m thankful my son is safe today. Questions. Why aren’t pregnancies with anterior placentas monitored more closely than other pregnancies? It seems like there’s so much that could be missed, though my experience, probably less common. Is there a better way to advocate for oneself in this type of situation? Thank you for all you do. Thank you for all you do. I look forward to hearing your response.”
All right. Kylie, thank you for that. I’m glad you’re well. Your baby’s well, of course. Okay. So, an anterior placenta, for our listeners, means the location of the placenta. And the placenta can sort of land anywhere in the uterus. If it lands on the top, meaning towards the mother’s belly, we call that anterior. If it lands on the back, meaning towards her back, we call that posterior. If it lands towards the top of the uterus, we will frequently call that fundal because the fundus of the uterus is the top of the uterus. And sometimes we’ll call it lateral, left lateral, right lateral if it’s on the left side or on the right side. And if it’s covering the cervix, we call it a placenta previa.
And there’s overlap. You can have a placenta…because the placenta is big. So, it can cover…part of it could be anterior and part of it lateral, part of it could be posterior, and part of it fundal, and so forth. Okay.
So, the issue here is that some women with an anterior placenta will feel less fetal movements, which makes sense because, frequently, the movements that women feel when they’re pregnant are the baby kicking…is the baby kicking upwards towards her belly. And if the placenta is between the baby and the top portion, and the front portion of the uterus anterior, it’s like there’s a cushion between the baby and the mother, almost like the baby has to kick through a pillow. And so, frequently, when there’s an anterior placenta, women will note that it’s later in pregnancy when they feel the baby moving, and they will have a harder time ascertaining when the baby is moving or not moving.
And you’re correct. It does sometimes present a conundrum because we always tell them, keep an eye on how the baby’s moving. How’s the baby moving, is the baby moving? We ask all these questions and give so much importance to how the baby’s moving and how a woman feels the baby’s moving. But if she’s feeling the baby move less and there’s an anterior placenta, well, should we be worried? Should we not be worried? And there isn’t a perfect answer to this question, as your doctor said.
One reason is that, although we always will tell women to be sort of on the lookout for how the baby’s moving, it’s not entirely clear how much that does or does not prevent bad outcomes in the baby. Meaning, this idea of should women do formal kick counts? Should they keep a sense of how the baby’s moving? And if they do, will it somehow pick up a problem in advance and prevent a problem? Is that something that’s real or is that something that just we’re trying to get to but don’t really achieve? And the data is very mixed on this, whether it actually is helpful. Most of the data suggests it’s not helpful in preventing stillbirth. Doesn’t mean we don’t do it, but whether it’s a valuable exercise to focus on the baby’s movement like this is debatable.
Now, still, if women do feel decreased movement, they say, hey, my baby was moving in a certain way or my baby normally moves a certain way, and now, today or the past couple of days or whatever it is, I feel the baby moving less, something has changed, we always take that seriously. And what we typically will do is double check, is that really true? Maybe try lying down, focus on the baby, eat something, do whatever tricks to sort of just ensure that in fact the baby’s not moving properly according to her sensation. And then we will usually bring them in and check and either…it depends on how far pregnant she is, what’s going on, whether we do a quick ultrasound, whether we do a non-stress test, whatever it is, we try to evaluate.
And fortunately, the vast majority of the time, even in that circumstance, everything is okay with the baby, baby’s moving fine, and she goes home and everything’s okay. Every now and again, we will pick something up like happened to you.
Now, is it directly related to the baby not moving? Could be. Obviously, that is certainly a possibility. Sometimes these things can be coincidental. Again, I don’t know if your story is specifically related to the baby’s movements because it was sort of picked up not because you had a unique complaint that day that the baby wasn’t moving well, but it was they just sort of found it at a routine visit. So, I don’t know if what they found with you is or is not related to the fact that you had felt less movements sort of earlier in pregnancy. Again, maybe yes, maybe no. I don’t know the answer to that question. And so, it is a complicated subject and topic. And so, what do we do practically?
Ultimately, I would say, we don’t usually focus on the fact that the placenta is anterior. I think what we try to do, which is I think what your doctors tried to do is, all right, do your best to get a sense of how does the baby normally move? What is a typical day like? And again, it doesn’t always work for everyone. And if there’s a concern, we will evaluate it and do our best to make sure that everything’s okay. Fortunately, usually, everything is okay. And so, fortunately, we can usually be very reassuring.
When we have circumstances with women who either with an anterior placenta or without an anterior placenta just don’t feel good fetal movements, they just never get that reassurance, that’s also a tough situation. What do you do? And every time you check, everything’s okay. It depends on the exact circumstances. Sometimes we’ll just play day by day or week by week and how they feel. Other times we’ll say, you know what, just come in every once a week or twice a week or whatever it might be. And we’ll just check just so you get that formal assessment. You’re reassured, we’re reassured. And again, does it actually help or not? I don’t know. Does it help relieve anxiety? Definitely. So, that’s valuable as well.
But it is a tough situation because there’s so much we don’t know. And a lot of this is obviously subjective, how you feel the baby moving. Like you said, you can see the baby moving on ultrasound, but not feel the baby moving. Well, is that concerning? Is it not concerning? Probably not, if the baby’s actually moving.
And so, it is not an easy thing. And we just try to, you know, individualize it and just figure out for each person what is the best way that she and we can be reassured that the baby is healthy. I know that wasn’t a perfect answer to your question, but that’s because there really isn’t a perfect answer to your question.
Okay. Next question is from an anonymous listener about exposure to chemotherapy while pregnant. “Hi, Dr. Fox. Absolutely love the podcast. I’m a mom of two, not currently pregnant, but still find all your topics fascinating and informative.” Hey. Thank you. “I recommend it to all my friends who are moms or soon-to-be moms.” Great. Another one who recommends us. Thank you so much. “My question. I’m a nurse working in oncology infusion department, and I have been since before I got pregnant with my first son. When I did find out I was pregnant with him, obviously, I had immediate concern about the risks of hanging chemotherapy if there were any. I called my OB right away, and he assured me it was safe as long as I wore proper protective equipment, which we do. We wear gowns and double-glove every time we hang chemo.”
“Also, in my department, the nurses don’t mix the chemo.” For those who don’t know what that means, that means actually getting in there and, you know, injecting this into this to make sort of the preparation. “The pharmacy does, which I feel like eliminates significant risk of exposure as well. I worked with chemotherapy during both my pregnancies and I have two healthy boys, thankfully. I’m curious what your take on this is and what you advise your patients to do if they work with chemo or in other hazardous conditions in the medical field. Thanks again for all you do.”
So, on a high level…and I’ll get to your specific question. On a high level, there’s always concern that pregnant women have about exposures, like environmental exposures. And there’s always a little bit of a challenge because not everyone knows exactly what the exposure is, how much they’re getting, how much risk there is. And there’s obviously different levels of precautions people take based on their individual circumstances and exposures, and also based on their own anxieties. And that’s fine. Some people, if it’s in the winter and they’re going to be in a crowded place, they just feel more comfortable wearing a mask. I would say that has picked up a lot since COVID time that more people are more comfortable wearing a mask in public places than they may have been before. And other people don’t feel the need to do that.
And, you know, which is better? I mean, yes, wearing a mask might be more protective. It might slightly lower the risk of you getting certain respiratory infections. Is it necessary? Well, you know, it depends on the circumstance. I don’t tell all my pregnant women they have to wear masks all the time. And it just sort of depends on everyone’s level of comfort. And people have to be comfortable with their life and their exposures. And everyone falls differently along the spectrum. And that’s fine. That’s sort of like in a general sense.
In terms of exposure to chemotherapy, there is some of that on a general sense and some of that on a specific sense. On a specific sense… So, there’s really good data that just being exposed in the terms of being in the room with someone, like someone…you have a friend or a family member who’s getting chemotherapy and they’re sitting in an infusion chair and you want to go visit them and sit with them, hold their hand, hug them, kiss them. There’s really good evidence that that’s not going to increase the risk to someone who is pregnant or someone who is not pregnant as well. And that that is sort of a safe endeavor. And so, that’s level one. Level two, which is what you’re talking about, is sort of, okay, I’m not just sitting with them and talking to them. I’m actually touching the bag of the chemotherapy. I’m hanging it. I’m attaching it to their IV. That’s a little bit higher-level exposure.
So, the data on that is mixed. I would say, there’s some evidence that people who have exposure like that to chemotherapy Asians who are pregnant, there is…some of the data suggest an increased risk of miscarriage, but no other increased risk, things like stillbirth or fetal growth restriction.
Now, the problem is a lot of that data is older, before a lot of the precautions were taken. Like you’re mentioning, the pharmacy mixing the drugs, wearing gloves, you know, all those things. And I think that most people are comfortable saying that the exposure you described sort of where you’re not mixing the drugs yourself, you’re wearing gloves, you’re wearing protective equipment, the likelihood that you’re going to get exposed to the chemotherapy in a way that would get in your bloodstream, get to the baby, cause a problem like miscarriage is…whether it’s zero or close to zero, hard to say, but it’s very, very low. And most people are comfortable saying that that is probably safe to do.
Obviously, everyone has their own level of comfort. Some people still might be uncomfortable with that situation. And there’s recommendations that pregnant women should be given the opportunity not to do that when they’re a nurse and this in case they’re uncomfortable with it. And it’s really not meant to force people to do something or not to do something, but just sort of similarly let people decide for themselves, are they willing to take very…let’s say a hypothetical risk or a low-level risk versus not. But most of the data would suggest that the…what you’re describing specifically is probably not particularly dangerous.
The third level of exposure is actually getting chemotherapy, receiving chemotherapy for cancer treatment when you’re pregnant. And interestingly, the risks of it are lower than people would have thought. And it’s fascinating and it’s hard sometimes to reconcile all the data. How does some form of environmental exposure to chemotherapy, being a nurse, let’s say, in the ’80s and hanging it and mixing it, how did it cause miscarriage exactly? And we’re not really sure. Did enough really get in her bloodstream that would go to the baby and cause a miscarriage? You would think she’d be sick if that happened.
And so, it’s really hard to know. Is it really true? Is that really what happened? Or maybe that there was just some other reason that there was an increased risk of miscarriage. It’s very hard to know the answers to these questions because the only way to have really good data on this, like solid data, is to take 2,000 pregnant nurses and have a thousand of them sort of mix chemotherapy and administer it, and the other thousand not do that and see who miscarries more. But who’s going to sign up for that study? How are you going to get people for that study? It’s just so impractical that you’re never going to have that study. So, they sort of look backwards and try to figure out nurses who are exposed versus not exposed.
Then you get into issues of something called recall bias, where maybe people who miscarried are more likely to sort of answer a survey and say, oh, yeah, I was exposed to chemotherapy, versus people who had a healthy pregnancy don’t even answer the survey or this. There’s so much background noise in a lot of these studies, for lack of a better term, that it’s hard to know definitively even in the studies that showed a slight increased risk of miscarriage with exposure. Was it really from the chemotherapy? Was it not from the chemotherapy? And it’s another reason why there’s some uncertainty about how cautious do people really need to be.
So, I think that, again, we tend to be cautious with pregnant women. That’s just sort of how we’ve all…we all function. You know, pregnant women like to be more cautious, and the people around them like to be more cautious with them. And I think that’s obviously appropriate and people are expecting or understandably, you know, worried and nervous and they don’t want to do anything, that’s wrong. All good, all fine.
And so, I think that in a situation like this, where the exposure is probably extremely low and the chance that it’s going to cause a problem is also probably very low and you multiply those by each other because it’s very, very low, I would say many — I don’t know if it’s most, I’m just not sure — nurses would be comfortable continuing their job under the…with the protection that you mentioned. And maybe some are not, and that’s fine, too. And then they would just, you know, ask to maybe be switched to another unit or have another sort of job requirement during that time period.
All right. Interesting stuff. Last question today is from Tina, and it’s about a history of placenta accreta spectrum. “Hi, Dr. Fox. Love the podcast. It has been such a great resource to me and my husband through my pregnancy journey.” Hey. Thanks, everyone, for sending the positive vibes at the beginning of your question. I really do appreciate it. All right. “My two pregnancies thus far have been complicated by placenta accreta spectrum. And I wanted to get your advice on what to expect if I try for a third baby.”
“For some background, I had no uterine surgeries going into my first delivery. So, it was a surprise when I ended up having a focal accreta requiring two units of blood, an emergency D&C, a Bakri balloon. My second pregnancy had serial ultrasounds by MFM until 32 weeks, an MRI 20 weeks that revealed no evidence of placenta accreta. But at delivery, I had a difficult manual removal of my placenta, lost one unit of blood, although this time I did not require a blood transfusion. The placenta pathology report showed stage two basal plate myometrial fibers, but did not confirm placenta accreta at that time. I also needed a hysteroscopy at four months postpartum to remove a 3 by 5 by 2 centimeter adherent piece of my placenta at the uterine fundus, which confirmed placenta accreta spectrum.”
“I’m currently 34 years old and have been contemplating trying for a third baby, but like to understand your thoughts on, one, is it a reasonable decision for me to get pregnant again? And, two, how would you anticipate my future pregnancy would go, given my history of placenta accreta spectrum? I would plan to deliver at a large teaching hospital with a placenta accreta program and a large blood bank. Thank you.” Long question, great question. This absolutely comes up a lot. So, thank you for that, Tina. Here we go.
So, for our listeners, background. Placenta accreta spectrum is essentially a term that helps describe and explain the fact that people with placenta accreta, where the placenta is stuck to the uterus, are not all the same. And there is sort of varying levels of severity. So, the most…the traditional placenta accreta, when we think placenta accreta, basically, the whole placenta is stuck to the uterus. It does not come out after delivery. Very high risk of hemorrhage and very bad things happening. Usually, it’s treated with a hysterectomy, remove the uterus after delivery. It’s hopefully known about or suspected before delivery. In which case, you can plan for this, have all the people around, have the blood around. In which case, outcomes tend to be very, very good. If it is found surprisingly at delivery, where it’s totally unexpected, it can be very, very dangerous to the mother. Usually not so much for the baby because it’s usually found out after the baby’s born, but it could be dangerous for the baby if she comes in premature, preterm, and bleeding. But that’s sort of what people think of as placenta accreta.
But there’s also people who the placenta comes out after delivery and there is a small portion that’s remaining behind that is causing problems. Some people have small portions of placenta that remain behind that do not cause problems at the time of delivery. Meaning, the delivery is uncomplicated, placenta comes out, everything’s fine, not a lot of bleeding, she feels great, she goes home. And then four weeks later, she has some irregular bleeding. We see her in the office, we do an ultrasound. We’re like, hey, there’s a little tiny piece of placenta that didn’t come out. It was stuck to the uterus. And then it either comes out later on its own or, like you had, we do a hysteroscopy, remove it later.
So, that’s the mildest, mildest, mildest form. We don’t even usually think of that as placenta accreta spectrum, although it might be, but that’s a very, very tiny thing. And then what you had is somewhere in between those two. So, the placenta did come out, but it was not an uncomplicated delivery. You had a lot of bleeding, and you had a blood transfusion, and they had to put the balloon in your uterus to stop the bleeding. And ultimately, there was the suspicion that the reason you were bleeding was because there was a portion of placenta that stayed behind of what we call the focal accrete, and that needed to be treated and this and that, fine.
And so, in your second pregnancy, because you had in your first, they were correct and wise in saying, hey, you had this once, we don’t know really why you had it. You didn’t have any risk factors for it as you mentioned. The biggest risk factor is having prior uterine surgery or a condition called Asherman’s is another reason someone has it. You didn’t have anything like that. They’re like, all right, in your next pregnancy, they probably said, maybe it’s going to happen again. Maybe it won’t. Let’s follow you very closely and look to see if it’s happening.
And they’re really…when they’re doing that, they’re looking for the full placenta accreta because that’s something that…not always, but often you can suspect on ultrasound or MRI and they’re saying, all right, we want to make sure you don’t have the thing that if we don’t know about it, your life is at risk. And so, they didn’t see any issues with the placenta. They did not see that kind of placenta accreta. You have your next delivery, but again, there’s a small portion of placenta that remains behind. It does not mean that they missed it because that’s something you can’t often see on ultrasound or MRI because it’s not that it’s a huge placenta accreta where the whole placenta is stuck. And it’s not typically invading deep into the uterus where you can sort of see that on imaging.
It’s just, for whatever reason, at that molecular level between that little portion of the placenta and the uterus, it was not the type that separates easily, and it was a type that separates a little bit more difficult. So, you had borderline complicated delivery, I guess, extra bleeding, but not a blood transfusion. And then you did have a little portion of placenta that had to be removed afterwards.
So, now, you’re talking about a third pregnancy. And what I would tell you is it’s unknown. We have had people with similar situations where the third pregnancy, nothing happens. The placenta just comes right out and everything is fine and all is well. And we’ve had people who come back and they have a very similar story to your first or your second where a portion of the placenta doesn’t come out and either that does lead to heavy bleeding or doesn’t lead to heavy bleeding, and either does lead to needing to remove a little piece of placenta later by hysteroscopy or doesn’t lead to that.
I would say, occasionally, we’ll get the full-blown accreta spectrum the third time, which is obviously the worst case scenario. But it’s not that common, I would say, for someone who’s had two stories like yours. And so, in terms of counseling, what I would say is, I don’t know how your pregnancy is going to go, given your history. I would say, the most likely is it’ll be somewhere in the middle that you’ll have some portion of your placenta remaining behind. Why that is, we don’t really understand. But since it happened twice, you would assume there’s a good chance it’ll happen again. In which case, we’ll do our best that the delivery is not crazy complicated, that you’re not sick.
Like you said, you’re delivering at a good place and you have blood available, and maybe you’ll need to have another hysteroscopy after delivery to remove it. Then there’s also a reasonable chance that nothing will happen, and you’ll have an uncomplicated delivery and placenta. And there’s a small chance that you will have a full-blown accreta spectrum. So, I would still do all the serial monitoring, maybe an MRI, have people available when you deliver, things like that.
It’s hard to give you exact numbers on those. It’s different for every person, but that’s sort of an overall sense of what I think. And then when you’re pregnant, assuming you do it, again, all the same things. Follow closely with ultrasound just to make sure there’s nothing really crazy going on with the placenta. It doesn’t look like a…does not look like a full-blown accreta spectrum. Maybe or maybe not do an MRI. There’s different philosophies on that, whether you should or shouldn’t. Some of it depends on how the ultrasound looks. And at the time of delivery, you, the doctor, everyone should be aware that this is a possibility, that you may have a portion of your placenta that’s stuck, and you might need extra treatments or blood or whatnot.
And again, hopefully, it’ll all go very well and very smooth and no issues, or if there’s any issues, they’ll be dealt with quickly and safely. And so, your birth can be more like the second one. And obviously, there’s a small chance it could be worse. But if you’re delivering at a place with…who’s used to this and with good doctors and nurses and a blood bank, God willing, you and your baby should still be well.
All right. Thank you all for your questions. Please do keep sending them in. Have a wonderful day. See you next week.
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